Fillable Office of International Admissions I-20 Request Form (Palm Beach State College)

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Office of International Admissions I-20 Request Form (Palm Beach State College)

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The Office of International Admissions I-20 Request Form (Palm Beach State College) form is 3 pages long and contains:

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  • 35 check-boxes
  • 77 other fields

Country of origin: US
File type: PDF

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International Admissions
4200 Congress Avenue
Lake Worth, FL 33461-4796
Ph: (561) 868-3029 Fax: (561) 868-3623
Office of International Admissions I-20 Request Form
Palm Beach State Student ID #: ______________________________________________________________
Name Mr. Mrs. Ms. __________________________________________________________________________
Last First Middle/Maiden Suffix
Today’s Date: __________________ Email Address: ____________________________@_______________
1. Purpose
a. Initial I-20
b. Change of Status
c. Continued Attendance
d. Transfer
e. Program Extension
f. OPT/CPT
g. Dependent I-20
h. Lost I-20
i. Reinstatement
j. Other ________________
k. What visa/status do you presently hold? F1 F2 B1/B2 M1 Other: __________________
l. What visa are you applying for? F1 M1 Other: __________________
m. Will you be applying for the student visa in your country? Yes No
n. Will you be applying to change your visa status in the U.S.? Yes No
2. Name (as it appears on Passport) Please Print.
Family or Last Name
First Name
Middle Name
Suffix
3. Other Information
Date of Birth (MM/DD/YYYY)
Gender
Country of Citizenship
Male Female
4. Current or Intended Educational Program at PBCC
Associate of Arts (AA) Associate in Science (AS) Bachelor of Applied Science (BAS)
Major:
5. Immigration Transfer Information (Required if transferring from another educational institution in United States)
School Transferring From:
International Admissions
4200 Congress Avenue
Lake Worth, FL 33461-4796
Ph: (561) 868-3029 Fax: (561) 868-3623
6. Immigration Documentation (Provide readable copies of following documents if you are/have been in the United States)
Passport #:
Copy of your Passport (Visa and bio pages)
Date of Expiration of Passport:
I-94 #:
Copy of your I-94 (front and back)
Copies of all previous I-20’s
7. Foreign Address: Required (Address in Home Country)
Street Address:
City:
Province/Territory:
Postal Code:
Country:
8. Local Address: Required (No P.O. Box address)
Street Address:
City:
State:
ZIP Code:
Country:
Telephone Number:
9. Employment Information (Only if obtaining an I-20 for CPT or OPT)
Employment Type: OPT CPT On-Campus Economic Hardship
Prospective Employer Information
Name of Employer:
Address of Employer:
City:
State:
Zip Code:
Duration of Employment:
From: __________ to __________
10. Financial Information (for New Students/Change in level/Program Extension/Adding Dependent)
If submitting Bank Statement, statement must be in English and must indicate a US dollar equivalent. Document date cannot
be older than 6 months before start of classes for the applied term. You must submit evidence of financial support in the
amount of $24,000.00 for the AA/AS degree programs or $28,750.00 for the BAS programs.
International Admissions
4200 Congress Avenue
Lake Worth, FL 33461-4796
Ph: (561) 868-3029 Fax: (561) 868-3623
11. Dependent Information (Financial Requirement for each Dependent is US $ 5,000.00)
Please provide a copy of the passport bio/visa pages for each dependent
Dependent 1
Dependent 2
Relationship:
Spouse Child
Spouse Child
Family Name:
First Name:
Middle Name:
Suffix (if applicable):
Date of Birth (mm/dd/yyyy):
Gender:
Female Male
Female Male
Country of Birth:
Country of Citizenship:
Foreign Street Address:
City:
Province/Territory:
Postal Code:
Country:
I declare the information above is accurate and true to the best of my knowledge. I understand that any
omission or falsification may result in my rejection or dismissal from the College.
Signature: ______________________________________________ Date: ______________
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Office of International Admissions I-20 Request Form (Palm Beach State College)

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Completed 1 February 2021

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